SOUTH WEST STRATEGIC HEALTH AUTHORITY LEARNING AND DEVELOPMENT STRATEGY, 2008 - 2011
2: The Policy Context: Meeting 21st Century Service Needs
3: Aligning Learning and Development with Workforce Planning and Agreed Clinical Vision
4: Using a Learning Architecture Model to Plan Investment
5: Strategic Building Blocks 2008/9
6: Evaluation and Review
8. Generic Learning & Development Agreement
1.1 The Learning and Development Strategy aims to identify the developments which need to occur, and where investments need to be made, to achieve the priorities of the Workforce Strategy (January 2007). It is focussed on delivering national priorities, and arranged around the delivery of care pathways.
1.2 The Learning and Development Strategy also aims to support the NHS strategic vision, as described in the NHS Operating Framework 2008/09:
‘Training and development effectiveness matters to staff when it is relevant, useful and supports the delivery of high quality care. That is why we are increasing the Multi-Professional Education and Training (MPET) budget by 6% in 2008/09 on the nationally allocated budget for 2007/08. We expect all trusts to use their service plan and clinical vision as the basis for a learning and development plan for closing the gap between current capability and capabilities needed for the future. There also need to be clear measures of progress, and this should be supported by systematic feedback from staff about training effectiveness…..PCTs, together with their SHAs, will wish to ensure that local Learning and Development Agreements properly reflect the requirements of providers’ workforce delivery plans and are aligned with the agreed clinical vision for service provision’.
1.3 The Learning and Development Strategy will be iterative, and will adapt to NHS policy drivers as they emerge. The first stage of the work will focus on four key themes of current learning and development strategy, and the changes which need to be made to ensure that public investment continues to be fit for purpose. These are:
· Development of the professionally registered workforce;
· Widening participation, particularly for staff working at Agenda for Change bands one to four;
· Postgraduate medical and dental education, in particular, the application of the Medical and Dental Education Levy (MADEL);
· Learning infrastructure, especially knowledge management and e-learning.
1.4 The second stage of the work will focus on evaluation and review – of the effectiveness of the overall strategy, and also the mechanisms employed for evaluating the benefits to healthcare of investments in education and training made by the Strategic Health Authority.
1.5 The key principles of the Learning and Development Strategy will be reflected in the Learning and Development Agreements between the Strategic Health Authority and NHS Trusts.
2.1 The key strategic trends can be summarised as follows:
|20th Century Healthcare||21st Century Healthcare|
|Hospitalisation||Care at or close to home|
|Professional Led||Patient Led|
|Activity Focus||Patient Safety and Quality Focus|
|Top Down Targets||Self Improvement|
|Provider Led||Commissioner Led|
|Declining Productivity||Improving Productivity|
|Impersonal Care||Personalised Care|
|High Growth||Low Growth|
2.2 In ‘Our NHS, our future’ (2007) Lord Darzi sets a vision for the NHS which is:
· Fair: equally available to all, taking full account of personal circumstances and diversity;
· Personalised: tailored to the needs and wants of each individual, especially the most vulnerable and those in greatest need, providing access to services at the time and place of their choice;
· Effective: focused on delivering outcomes for patients that are among the best in the world;
· Safe: as safe as it possibly can be, giving patients and the public the confidence they need in the care they receive;
· Locally accountable: so that staff are empowered to lead change and innovate locally, ensuring that this is based on the best clinical evidence, meets local needs, and is the product of engagement with patients and the public.
The South West Strategic Health Authority’s plan for translating this vision into local achievement is set out in ‘Improving health: ambitions for the South West’ (June 2008), which describes the work of nine Clinical Pathway Groups covering the following areas:
· Staying healthy
· Maternity and newborn care
· Children and young people
· Long term conditions
· Mental health
· Learning disability
· Planned care
· Acute care
· End of life care
2.3 From a patient perspective, the most important thing is the quality of service delivered within the care pathway. The NHS is structured like a layer cake, with primary care as the base, secondary care in the centre and tertiary care at the top. Most patient pathways do not progress beyond the bottom layer, and may involve non-NHS organisations like schools, care homes or charities. Investment in education and training is, however, largely based on the top two layers, and is spent almost exclusively on NHS staff.
2.4 The challenge now is to work towards incremental change of this investment pattern, so that education and training is commissioned and delivered to enable the workforce to operate within the 21st century health care environment, and deliver patient specified, personalised care, as described in Lord Darzi’s vision.
2.5 A key principle for the South West Strategic Health Authority will be the alignment of education and training commissions with agreed clinical vision, in line with the guidance given by the Operating Framework 2008/09 (see 1.2 above). Agreed clinical vision will be based on best evidence, presented in the form of a care pathway and confirmed by Primary Care Trust commissioners, working to the Department of Health’s strategy for World Class Commissioning.
3.1 The NHS South West Workforce Strategy paper (January 2007) identifies the key national and local drivers which will impact on the workforce in the next phase of NHS development, and describes the way in which the workforce, including the contribution of new roles, must develop to support evolving service strategies.
3.2 The vision is a workforce which will be patient, rather than sector focussed, able to cross current boundaries. New roles will be based on competencies and care pathways, rather than traditional professional preparation.
3.3 As the Operating Framework points out, agreed clinical vision underpins care pathways. This is usually presented as NICE Guidelines or Health Technology Assessments, or local guidelines and procedures. Tools like the Map of Medicine, currently being implemented across the NHS as part of the Connecting for Health programme, enable this knowledge to be presented in a format which is accessible to clinicians and patients, and which can be localised to present commissioning patterns across a health community.
3.4 In terms of the development of evidence based care pathways, the NHS is, however, at the beginning of a journey which will be long and tortuous. There are major issues to resolve in the following areas:
· Improving patient safety;
· Unknowing variations in policy and practice;
· Failure to introduce high value interventions;
· Uncritical adoption of low value interventions;
· Failure to recognise uncertainty and ignorance.
(Gray, M (2008): Authority in the NHS.
Carruthers, I (2008). Tolerance of minor incidents needs major overhaul. Health Service Journal, 14 February, pp.18-19).
3.5 The World Class Commissioning initiative will be the key driver for improving services to patients and the public. Primary Care Trusts are the commissioners for health care in England, and will take responsibility for the effectiveness of care pathways. The required skills, which include excellence in managing knowledge and in promoting improvement and innovation, are described in World class commissioning: competencies (2008).
3.6 Primary Care Trusts will need to play a greater role in commissioning and training the health care workforce in order to ensure that effective care pathways are delivered. The Strategic Health Authority will promote the role of Primary Care Trusts in identifying workforce development need in local health communities. The management process for this is described in Appendix One: Strategic Service Improvement Funding .
3.7 The Strategic Health Authority will work towards building a health service workforce which is appropriately skilled to deliver effective care pathways at all levels. There has been under-investment in the education and training of workers at Bands One to Four of Agenda for Change: this will be addressed through the Widening Participation Strategy (Appendix Two).
3.8 The Strategic Health Authority will also ensure that Primary Care Trusts have access to information services to support evidence based decision making and leadership in improvement and innovation. The processes for achieving this are described in Appendix Three: Postgraduate Medical and Dental Education, and Appendix Four: Learning Infrastructure.
4.1 The Workforce Strategy Paper notes that in spite of initiatives such as the introduction of ambulance service emergency care practitioners and physicians’ assistants, ‘few organisations have adopted roles or ways of working systematically with a clear evaluation of the impact on service delivery and costs’.
4.2 In line with the requirements of the Operating Framework, investment in education and training needs to align clearly and transparently with service plans, clinical vision and patient choice. This will involve adopting less traditional approaches, innovation from current education providers, and working with new providers.
4.3 The education and training inputs we need to commission can be more closely defined by applying a learning architecture model to care pathways. The Map of Medicine palliative care pathway, for instance, takes place entirely in primary care, which is often in accordance with patient choice. It involves multiple agencies, which can often be a negative factor in patient experience. An analysis of the pathway reveals many potential training and learning needs, which would be difficult to meet using traditional models of health care education. Some of these are shown in the model below.
4.4 Learning architecture: palliative care
|Training||Information/ Knowledge Management||Performance Support|
|e.g. Lifting and handling;
Recognising emergencies and complex problems; Nutrition
Consider using e-learning as a key training resource, which can be targeted at:
Health / social care professionals across multiple agencies;
|e.g. identifying best practice;
Libraries (including e-libraries like National Library for Health or NHS Choices)
Online knowledge sharing communities
Patient input, e.g. Macmillan Cancer Voices
Access to data and benchmarking tools
|e.g. applying best practice;
reversing poor performance
Leveraging organisational expertise
4.5 In this model, the most costly training resource, i.e. highly experience and/or qualified teachers, is deployed mostly in delivering performance support, which requires a high level of skill, and which is crucially important to improving standards in health care.
4.6 In order to deliver education and training aligned to care pathways, as illustrated in the Learning Architecture model, the Strategic Health Authority’s commissioning strategy will consider the following shifts:
|Allocation of continuing professional development funding is Trust / staff led||Allocation is aligned to agreed clinical vision via care pathways, and managed by Primary Care Trusts|
|Allocation of study leave funding for medical staff is Trust / staff led||Allocation is aligned to agreed clinical vision and managed strategically via Deaneries in collaboration with Primary Care Trusts|
|Non-medical commissions placed with higher education institutions||Non-medical commissions mostly with higher education institutions, but also providers such as organisations from the health care family and commercial suppliers|
|Education providers react to demand with long lead times for development||Education providers are adept at analysing education and training needs linked to care pathways, and are fleet of foot|
|Commissions are mostly traditional face to face training courses||Commissions also include e-learning, work based learning, support for informal learning, designed according to a care pathway’s learning architecture model|
|Clinical placements mostly in the NHS||Clinical placements in new care delivery settings, such as patients’ homes, schools, care homes|
|Commissions are for NHS staff||Commissions can be used to up-skill other members of the health care family, such as carers, patients, charity workers|
|Commissioning decisions made by the Strategic Health Authority||Commissioning decisions made by Primary Care Trusts, influenced by service users, health care providers and education providers|
|Evaluation focuses on student experience||Evaluation focuses on health care outcomes / quality of life outcomes for patients|
4.7 The Strategic Health Authority will encourage education and training commissioners to use the multi-professional education and training levy to commission training and learning inputs which support evidence based care pathways.
4.8 Training and learning inputs, including investment in the learning infrastructure, will be multi-professional where appropriate, and will be delivered across sectors where there is an identified patient need.
4.9 Training and learning strategies to support care pathways will be led by Primary Care Trusts, and will link closely to plans to deliver world class commissioning.
4.10 The Strategic Health Authority’s strategy for achieving this is described in section 5 (below) and in the Appendices.
5.1 Developing the Professionally Registered Workforce
Appendix One describes the Strategic Health Authority’s plans to establish a Strategic Service Improvement Fund. This will total approximately £4.5 million per annum, and will be formed by reconfiguring the Continuing Professional Development Fund, traditionally used to support the ongoing training needs of nurses and allied health professionals by purchasing courses from Higher Education Institutions.
The Strategic Service Improvement Fund will be managed by Primary Care Trusts, and will be used to ensure that the workforce resources for the effective delivery of care pathways are in place. Its administration will ensure that the taxpayer has clear evidence that investment in education and training is effectively geared to delivering health service priorities.
Some Primary Care Trusts will begin to implement the Strategic Service Improvement Fund in 2008/9. The rest will perform a shadowing exercise, with a view to implementation from 2009/10 onwards.
5.2 Widening Participation
Appendix Two describes the strategic direction NHS South West will take to support wider participation in learning by NHS staff working at Agenda for Change bands one to four. It aims to reinforce the crucial role these workers play in achieving the delivery of successful care pathways, by spearheading investment in their education and training.
Working with the Learning and Skills Council and Skills for Health, the Strategic Health Authority will invest £2 million in training for this group of staff during 2008/9. In addition, the Learning and Skills Council will invest £1 million, and £1.75 million will also be made available from the Widening Access to pre-registration education initiative. The total fund of £4.75 million will be managed through the Joint Investment Framework. All Trusts and Primary Care Trusts in the South West have signed a pledge to support the work.
5.3 Postgraduate Medical and Dental Education
Appendix Three describes the harmonisation of funding streams to support medical education and learning infrastructure in NHS South West. The initial focus, to be applied from 1 April 2008, is the Medical and Dental Education Levy (MADEL), specifically the following areas:
Libraries (£1.9 million)
Non-pay funding based on trainee numbers (£3.6 million)
Postgraduate Medical Centres (£3.8 million)
The harmonisation exercise applies a formula for allocating these funding streams to NHS Trusts. Receipt of funding is governed by the Learning and Development Agreement, which sets out how the money should be used within the context of the strategic aims of the Learning and Development Strategy.
5.4 Learning Infrastructure
The Strategic Health Authority invests approximately £2.5 million per annum in learning infrastructure (excluding postgraduate medical centres). Plans for strategic development are described in Appendix Four. Key action points for 2008/9 are:
· Implementation of the National Learning Management System, based on the Electronic Staff Record, in NHS South West;
· Support for the change management process to accompany the introduction of e-learning;
· Procurement of e-learning content based on nationally developed, evidence based and quality assured resources, which contributes to national and local priorities;
· Knowledge management support for world class commissioning through Primary Care Trusts, including the implementation of Map of Medicine;
· Knowledge management support for public health and patient choice;
· Benefits realisation from investment in other learning technologies, such as video conferencing facilities.
The strategic shifts described in this document represent significant changes for the way education and training is commissioned and delivered in the NHS. In order to assess the impact of this change, and to ensure that investments continue to align to the NHS strategic vision, an evaluation model will be commissioned during 2008/9 which will apply across medical and non-medical investments. Its ultimate aim will be to assess the impact of education and training investment on healthcare and quality of life outcomes for patients.
Department of Health (2007). The NHS in England: the Operating Framework for 2008/9 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications
Department of Health (2007). Our NHS, our future: NHS next stage review – interim report. http://www.dh.gov.uk/en/Publicationsandstatistics/
South West Strategic Health Authority (2008). Improving health: ambitions for the South West. http://www.southwest.nhs.uk/pdf/NEW%20NHS%20Ambitions%20Brochure%2014_05_08.pdf
Department of Health (2007). World class commissioning: vision. http://www.dh.gov.uk/en/Publicationsandstatistics/
Carruthers, I. (2008). Tolerance of minor incidents needs major overhaul. Health Service Journal, 14 February, pp. 18-19.
Gray, M. (2008). Authority in the NHS. In: Hill, P. Report of a national review of NHS library services in England.
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